PLEASE PROVIDE CONTACT INFORMATION REQUEST BELOW SO WE CAN ASSIST YOU

 

First Name   Last Name

 

Email Address

 

Contact Address:

Address   Address

  City State Zip Code  

 Contact Phone no:   Best Time to Call

 

Delivery Address:          (Same as Contact Address )       (Needed for Shipping Quote)       

Address   Address

  City State Zip Code  

 Contact Phone no:   Best Time to Call

 

CUSTOMER MESSAGE TO BNSE MOBILITY

MEDICAL EQUIPMENT VENDOR

    

 

MEDICAL EQUIPMENT INTEREST

 PLEASE CHECK BELOW

 

If you know the 

Model, Part Number Enter Here:

Manufacture Name

Model Number         

Part Number           

 

Check Medical Equipment you need more information about:

ELECTRIC WHEELCHAIRS  
ELECTRIC CHAIRS
ELECTRIC THREE WHEEL SCOOTERS
ELECTRIC FOUR WHEEL SCOOTERS
HOSPITAL BEDS
HOSPITAL TABLES
MANUAL WHEELCHAIRS
ASSISTANCE WALKERS
OXYGEN CONCENTRATORS
OXYGEN REGULATORS
OXYGEN TANKS
OXYGEN TANK REFILL EQUIPMENT
ELECTRIC WHEELCHAIR AUTO LIFTS
ELECTRIC THREE WHEEL SCOOTER LIFTS
ELECTRIC FOUR WHEEL SCOOTER LIFTS
BATHROOM ASSISTANCE EQUIPMENT
TRANSFER CHAIRS
STOOLS
TOILET ATTACHMENTS
TUB ATTACHMENTS
WALKERS TWO WHEELS
WALKERS THREE WHEELS
WALKERS FOUR WHEELS
BED LIFTS
OTHER  

 

Other Medical Equipment

 

Additional information to

meet your individual needs.

Do you qualify for a power wheelchair?

Answer these 5 easy questions to find out if you are eligible:

1. Do you have problems throughout the day with your mobility due to your health?

 Yes
 No

2. Do you have trouble completing your daily activities due to heart, lung, arthritis, respiratory, stroke, diabetes, or any other health reasons?

 Yes
 No

3. If "Yes" to question 2, would a power wheelchair allow you to better complete your daily activities?

 Yes
No

4. Would a power wheelchair give you more independence and freedom of movement?

 Yes
No

5. Can you safely operate a power wheelchair?

 Yes
No

If you answered "Yes" to all of the above questions, you may be eligible

for insurance coverage for a power wheelchair

 

 

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